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SANITARY PERMIT APPLICATION GD NTY6 <br /> 0ILHR In accord with ILHR 83.05,Wis. Adm. Code ^(n� <br /> ST TESANITARYPE MIT# <br /> Irl l��d� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STA TE PLAN I.D.NU BER <br /> 8Yz x 11 inches in size. <br /> -See reverse side for instructions for completing this application. PE ITION <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOI I VARIANCE ❑YES ❑ NO <br /> PROPERTY OWNER PROPERTY LOCATION <br /> AC fl f Peal f' 2{/C 1/a SF_Ya, S o�s T 410 N, R E (or <br /> PROPERTY OWNER'S MAILINGADDRESS LOTNU BER BLOCKNUMBER Cyn V n 066'1 60 <br /> 7 <br /> C Y,STATE 1 T ZIIP-CODE PHONE NUMBER CITY NEA EST R AD,LAKEORL,AIJDMARK <br /> CC/ (LLv 7a 3 o�� ❑ VIOWN <br /> LLAGE <br /> : UCI�Y7 /17 �CQ�CI <br /> II. TYPE OF BUILDING OR USE SERVED: <br /> Number of Bedrooms if 1 or 2 Family -� OR ❑ Public(Specify): <br /> Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4, if applicable) <br /> 1. a. 0New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. Repair of an <br /> System System Septic Tank Only an Existing System Existing System <br /> 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. <br /> 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreeme it to County Copy. <br /> IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) <br /> 1. a. XConventional b. ❑ Alternative C. ❑ Experimental <br /> 2. a. ❑System- b. ❑ Holding c.L1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El IGP <br /> In-Fill Tank <br /> V. ABSORPTION SYSTEM INFORMATION: (Check one) <br /> 1. a. 0Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit <br /> 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WP TER SUPPLY: <br /> (Minutes per inch): REQUIRED//(Square Feet): PROPO'SEED�(S are Feet): D <br /> Y/7- / 7 Feet P ivate ❑Joint ❑ Public <br /> VI. TANK CAPACITY Site <br /> in 11 ns Total #of Manufacturer's Name Prefab. Con- Stee Fiber- Plastic Exper. <br /> INFORMATION New Existing Gallons Tanks Concrete glass App. <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tank 7`S� 5'0 1 1 1 mCi ❑ ❑ Ll Pum Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:( [am s) MP/MPRSW No.: Bu iness Phone Number: <br /> u/ade /Qu Gho/m SS&/ /s PGG- 7WP* <br /> Plumber's Address(Street,City,State,Zip Code): Name of Designer: <br /> (a /-W/Ave.-l-, Po.,cso as <br /> VIII. SOIL TEST INFORMATION <br /> Certified Soil Tester(CST)Na e CST# <br /> KI <br /> Qa'e ,eu fs/w�m 3 y3 <br /> CST's ADDRESS <br /> ,,((SStreet,City,Stale,Zip Code) Phone Numb r:: <br /> E <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sani ry Permit Fee Groundwater ate Issui A ant Si natu (N Stamps) <br /> Approved F7 Owner Given Initial S rcharge Fee <br /> Adverse Determination � •� as. <br /> X. COMMENTS/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber <br />